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Competing Interests: Disclosures The authors have no conflicts of interest to disclose.

The presence of symptoms plays an important role in determining whether to focus on rhythm control or rate control when treating atrial fibrillation (AF). Previous comparative studies on the clinical outcomes of symptomatic and asymptomatic AF have yielded inconsistent results, and a link between AF symptoms and left atrial (LA) remodeling is not established. Patients selected from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, which is a prospective, multicenter study consisting of patients with non-valvular AF, were grouped into 2 groups: symptomatic and asymptomatic. The primary outcome was a composite of the following cardiovascular outcomes: all-cause death, ischemic stroke, transient ischemic attack, systemic embolism, myocardial infarction, and heart failure hospitalization. Of 10,210 patients with AF, 4,327 (42%) had symptomatic AF. The asymptomatic group had an older mean age, more men, and more patients with hypertension and diabetes mellitus than the symptomatic group. The asymptomatic group had a larger left atrium (LA) diameter (43.6 vs 42.2 mm, p <0.001) than the symptomatic group. During a median follow-up of 32.9 (29.5 to 36.4) months, the asymptomatic and symptomatic groups showed similar incidences of the primary outcome (1.44 vs 1.45 per 100 person-years; log-rank, p = 0.8). In conclusion, the absence of AF symptoms is associated with increased LA. However, symptomatic and asymptomatic patients with AF have a similar risk of cardiovascular outcomes. This suggests that beneficial treatment for AF may be considered regardless of whether patients have symptomatic or asymptomatic AF., Competing Interests: Declaration of competing interest Dr. Joung has served as a speaker for Bayer, BMS/Pfizer, Medtronic, and Daiichi-Sankyo and has received research funds from Medtronic and Abbott. No fees were received, either directly or personally. The remaining authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no oral anticoagulant (OAC) in AF patients with advanced CKD or ESRD on dialysis., Materials and Methods: Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate <30 mL/min per 1.73/m²) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC groups; and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed., Results: During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group [hazard ratio (HR) 0.11, 95% confidence interval (CI) 0.01 to 0.93, p =0.043]. In addition, the risk of composite adverse clinical outcomes (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.16, 95% CI 0.03 to 0.91, p =0.039)., Conclusion: Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcomes compared to no OAC. ClinicalTrials.gov (NCT02786095)., Competing Interests: Dr. Boyoung Joung has served as a speaker for Bayer, BMS/Pfizer, Medtronic and Daiichi-Sankyo, and has received research funds from Medtronic and Abbott. All other authors declare no competing interests. No fees were received personally., (© Copyright: Yonsei University College of Medicine 2023.)

Purpose: Atrial fibrillation (AF) patients with low to intermediate risk, defined as non-gender CHA 2 DS 2 -VASc score of 0-1, are still at risk of stroke. This study verified the usefulness of ABCD score [age (≥60 years), B-type natriuretic peptide (BNP) or N-terminal pro-BNP (≥300 pg/mL), creatinine clearance (<50 mL/min/1.73 m²), and dimension of the left atrium (≥45 mm)] for stroke risk stratification in non-gender CHA 2 DS 2 -VASc score 0-1., Materials and Methods: This multi-center cohort study retrospectively analyzed AF patients with non-gender CHA 2 DS 2 -VASc score 0-1. The primary endpoint was the incidence of stroke with or without antithrombotic therapy (ATT). An ABCD score was validated., Results: Overall, 2694 patients [56.3±9.5 years; female, 726 (26.9%)] were followed-up for 4.0±2.8 years. The overall stroke rate was 0.84/100 person-years (P-Y), stratified as follows: 0.46/100 P-Y for an ABCD score of 0; 1.02/100 P-Y for an ABCD score ≥1. The ABCD score was superior to non-gender CHA 2 DS 2 -VASc score in the stroke risk stratification (C-index=0.618, p =0.015; net reclassification improvement=0.576, p =0.040; integrated differential improvement=0.033, p =0.066). ATT was prescribed in 2353 patients (86.5%), and the stroke rate was significantly lower in patients receiving non-vitamin K antagonist oral anticoagulant (NOAC) therapy and an ABCD score ≥1 than in those without ATT (0.44/100 P-Y vs. 1.55/100 P-Y; hazard ratio=0.26, 95% confidence interval 0.11-0.63, p =0.003)., Conclusion: The biomarker-based ABCD score demonstrated improved stroke risk stratification in AF patients with non-gender CHA 2 DS 2 -VASc score 0-1. Furthermore, NOAC with an ABCD score ≥1 was associated with significantly lower stroke rate in AF patients with non-gender CHA 2 DS 2 -VASc score 0-1., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2022.)

Background Atrial fibrillation (AF) is associated with an increased risk of poor cardiovascular outcomes; appropriate rhythm control can reduce the incidence of these adverse events. Therefore, catheter ablation is recommended in symptomatic patients with AF. The aims of this study were to compare AF-related outcomes according to a baseline symptom scale score and to determine the best treatment strategy for asymptomatic patients with AF. Methods and Results This study enrolled all patients who completed a baseline Atrial Fibrillation Effect on Quality-of-Life (AFEQT) survey in a prospective observational registry. The patients were divided into 2 groups according to AFEQT score at baseline; scores ≤80 were defined as symptomatic, whereas scores >80 represented asymptomatic patients. The primary outcome was defined as a composite of hospitalization for heart failure, ischemic stroke, or cardiac death. This study included 1515 patients (mean age: 65.7±10.5 years; 998 [65.9%] men). The survival curve showed a poorer outcome in the symptomatic group compared with the asymptomatic group (log-rank P =0.04). Rhythm control led to a significantly lower risk of a composite outcome in asymptomatic patients (hazard ratio [HR], 0.47 [95% CI, 0.27-0.84], P =0.01). Rhythm control was associated with more favorable composite outcomes in the asymptomatic group with paroxysmal AF, left atrium diameter ≤50 mm, and CHA 2 DS 2 -VASc score ≥3. Conclusions Symptomatic patients with AF experienced more adverse outcomes compared with asymptomatic patients. In asymptomatic patients with AF, a strategy of rhythm control improved the outcomes, especially with paroxysmal AF, smaller left atrium size, or higher stroke risk. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02786095.

Purpose: The incidence of stroke and/or systemic thromboembolism (SSE) has not been properly evaluated in well-anticoagulated atrial fibrillation (AF) patients. This study investigated the incidence of SSE according to CHA 2 DS 2 -VASc score in contemporary well-anticoagulated Korean AF patients., Materials and Methods: From the prospective multicenter COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry, we identified 9503 patients with non-valvular AF (mean age, 68±8 years; female 35.5%) enrolled between June 2016 and May 2020 with eligible follow-up visits. Stroke incidence in the CODE-AF registry was compared with that in an oral anticoagulant (OAC)-naïve AF cohort from the Korean National Health Insurance database., Results: The usage rates of OACs and antiplatelet agents were 73.5% (non-vitamin K OACs, 56.4%; warfarin, 17.1%) and 23.8%, respectively. During a mean follow-up period of 26.3±9.6 months, 163 (0.78 per 100 person-years) patients had SSE. The incidence rate (per 100 person-years) of SSE was 0.77 in the total population, 0.26 in low-risk patients [CHA 2 DS 2 -VASc score 0 (male) or 1 (female)], and 0.88 in high-risk patients (CHA 2 DS 2 -VASc score ≥2). Contemporary AF patients had a stroke rate that was about one-fifth the stroke rate reported in a Korean OAC-naïve AF cohort. In this cohort, most risk factors for CHA 2 DS 2 -VASc score showed significant associations with SSE. Female sex was not associated with an increased risk of stroke/SSE in well-anticoagulated AF patients., Conclusion: Contemporary AF patients have a stroke rate about one-fifth that in OAC-naïve AF patients and exhibit different stroke risk factors., Study Registration: ClinicalTrials.gov (NCT02786095)., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2022.)

Background and Objectives: In this study, we attempted to determine the effects of acupuncture on cardiac remodeling and atrial fibrillation (AF) recurrence rates in patients with AF after electrical cardioversion (EC). Materials and Methods: We randomly assigned 44 patients with persistent AF to an acupuncture group or a sham acupuncture group. An electroacupuncture treatment session was administered once weekly for 12 weeks at four acupuncture points (left PC5, PC6, ST36, and ST37). Results: Among the 44 recruited participants, 16 (treatment group) and 15 (control group) completed the trial. The three-month AF recurrence rate (primary outcome) was not significantly different between the two groups. Following the completion of treatment, patients who had been treated with acupuncture had a significant reduction in left atrial volume index (42.2 ± 13.9 to 36.1 ± 9.7 mL/m 2 ; p = 0.028), whereas no change in atrial size was observed in the sham acupuncture group. No serious adverse events were observed. The AF recurrence rate and cardiac function did not differ significantly between the two groups. At three months, the acupuncture treatment group showed more favorable atrial structural remodeling compared to the sham acupuncture group. Conclusion: In future research on acupuncture in AF management, it is recommended that the inclusion criteria be amended to include only symptomatic AF, that an appropriate control group is designed, and that the acupuncture treatment frequency is increased to several times per week.

We sought to evaluate the clinical implication of LAE based on left atrial anterior-posterior (LA AP) dimension or LA volume index (LAVI) in Korean patients with atrial fibrillation (AF). We enrolled 8159 AF patients from the CODE-AF registry. The primary outcome was rate of stroke or systemic embolism (SSE). The prevalence of mild, moderate, and severe LAE by LA AP dimension was 30.6%, 18.5%, and 21.4%, and by LAVI (available in 5808 patients) was 15.7%, 12.5% and 37.8%, respectively. Compared with no or mild LAE, patients with significant LAE (moderate to severe LAE, n = 3258, 39.9%) were associated with a higher rate of SSE (2.5% vs. 1.4%, P = 0.001). Multivariable analysis suggested presence of significant LAE by LA AP dimension was associated with a higher risk of SSE in the overall population (HR 1.57, 95% CI: 1.14-2.17, P = 0.005) and in patients using anticoagulants (n = 5836, HR 1.79, 95% CI: 1.23-2.63, P = 0.002). Patients with significant LAE by LAVI were also at higher risk of SSE (HR 1.58, 95% CI: 1.09-2.29, P = 0.017). In conclusion, significant LAE by LA dimension or LAVI was present in 39.9% and 50.2% of AF patients, respectively, and was associated with a higher rate of SSE., (© 2021. The Author(s).)

Aims: The aim of this study is to determine the relationship between alcohol consumption and atrial fibrillation (AF)-related adverse events in the AF population., Methods and Results: A total of 9411 patients with nonvalvular AF in a prospective observational registry were categorized into four groups according to the amount of alcohol consumption-abstainer-rare, light (<100 g/week), moderate (100-200 g/week), and heavy (≥200 g/week). Data on adverse events (ischaemic stroke, transient ischaemic attack, systemic embolic event, or AF hospitalization including for AF rate or rhythm control and heart failure management) were collected for 17.4 ± 7.3 months. A Cox proportional hazard models was performed to calculate hazard ratios (HRs), and propensity score matching was conducted to validate the results. The heavy alcohol consumption group showed an increased risk of composite adverse outcomes [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.06-1.66] compared with the reference group (abstainer-rare group). However, no significant increased risk for adverse outcomes was observed in the light (aHR 0.88, 95% CI 0.68-1.13) and moderate (aHR 0.91, 95% CI 0.63-1.33) groups. In subgroup analyses, adverse effect of heavy alcohol consumption was significant, especially among patients with low CHA2DS2-VASc score, without hypertension, and in whom β-blocker were not prescribed., Conclusion: Our findings suggest that heavy alcohol consumption increases the risk of adverse events in patients with AF, whereas light or moderate alcohol consumption does not., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: This study aimed to elucidate the risk for stroke and systemic embolism (SE) in patients with atrial fibrillation and heart failure (HF) according to HF type., Methods and Results: A total of 10 780 patients with atrial fibrillation were enrolled in a multicentre prospective registry and divided according to HF type: no-HF, HF with preserved ejection fraction (EF) (HFpEF), HF with mid-range EF (HFmrEF), and HF with reduced EF (HFrEF). Each group included 237 age-matched and sex-matched patients (age, 69.0 ± 10.3 years; men, 69.6%). The baseline characteristics, cumulative incidence, and hazard ratios for stroke/SE and major bleeding were compared across the groups. Patients with HF accounted for 10.3% of the total population; HFpEF, HFmrEF, and HFrEF represented 43.7%, 23.6%, and 32.7% of the patients with HF, respectively. The CHA 2 DS 2 -VASc score was significantly higher in the HFpEF, HFmrEF, and HFrEF groups than in the no-HF group. The annual stroke/SE incidence rates were 2.8%, 0.7%, 1.1%, and 0.9% in the HFpEF, HFmrEF, HFrEF, and no-HF groups, respectively. The cumulative incidence of stroke/SE was significantly highest in the HFpEF group at 22.8 ± 10.0 months (P = 0.020). The stroke/SE risk was higher in the HFpEF group than in the HFmrEF and HFrEF groups (hazard ratio, 3.192; 95% confidence interval, 1.039-9.810; P = 0.043). E/e' value was an independent risk factor for stroke/SE. There were no significant differences in the incidence of major bleeding across the groups., Conclusions: The stroke/SE risk was the highest in the HFpEF group and comparable between the HFmrEF and HFrEF groups., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background/aims: Comparative occurrence of ischemic stroke for rhythm versus rate control strategy in patients with non-valvular atrial fibrillation (NVAF) is still inconclusive. The purpose of this study was to investigate whether the rhythm control strategy is associated with a lower risk of ischemic stroke compared to the rate control strategy in NVAF patients., Methods: The CODE-AF registry prospectively enrolled 6,280 consecutive patients who were treated for NVAF at 10 tertiary referral centers in South Korea. Of these, 2,513 NVAF patients (age, 67 ± 10 years; male, 61.8%) were clinically followed up for over 1-year and divided into rate and rhythm control groups., Results: Those treated with the rhythm control strategy were younger and had less proportions of underlying disease compared to those treated with the rate control strategy. After the propensity matching analysis, those treated with the rhythm control strategy had similar baseline characteristics including the CHA2DS2-VASC score compared to those treated with the rate control strategy. The rate of oral anticoagulation, all bleeding, and hospitalization were also similarly between the two groups. The incidence rate of ischemic stroke in the rhythm control group was significantly lower than in the rate control group (0.7 vs. 6.9 per 1,000 person-years, p = 0.011)., Conclusion: The rhythm control strategy demonstrated a beneficial effect to lower the risk of ischemic stroke during a 1-year follow-up compared to the rate control strategy.

The relationship between atrial fibrillation (AF) type and stroke risk is still controversial. We investigated the difference of burden of atrial ectopic beats in different types of AF and the effect of the AF type on stroke risk in patients with non-valvular AF. In the prospective, multicenter observational registry with more than about 10,000 AF patients, 8883 non-valvular AF patients (mean age, 67.0 years; 36% were women) with eligible follow-up visits participated. We compared the burden of ectopic beats and stroke risk between patients with paroxysmal AF (n = 5,808) and non-paroxysmal AF (n = 3,075). The patients with a non-paroxysmal type of AF were older, male-predominant and had a higher prevalence of comorbidities and had more anticoagulation and rhythm control treatment than those with paroxysmal AF. In terms of the difference in burden of ectopic beats, patients with non-paroxysmal AF had a higher proportion of atrial premature beats (APBs) (paroxysmal vs. non-paroxysmal, median 3% vs. 5%; p = 0.001) in 24 hours Holter monitoring. During a median follow-up period of 16.8 months (Interquartile range [IQR], 11.67-20.52), a total of 82 (0.92%) patients experienced ischemic stroke with incidence rates of 0.50 and 1.09 events per 100 person-year for paroxysmal and non-paroxysmal AF, respectively. The cumulative incidence of stroke events was significantly higher in non-paroxysmal AF than in paroxysmal AF (p < 0.001). The risk of ischemic stroke was higher in non-paroxysmal AF with an adjusted hazard ratio (HR) of 2.08 (95% confidence interval [CI], 1.33-3.25; p = 0.001) than in paroxysmal AF. The type of AF was associated with an increased risk of stroke, along with the difference of burden of ectopic beats (specially in APBs) in different types of AF. These results suggest that the type of AF should be considered in stroke prevention and decision-making for oral anticoagulation in AF patients.

Purpose: Stroke prevention in patients with atrial fibrillation (AF) is influenced by many factors. Using a contemporary registry, we evaluated variables associated with the use of warfarin or direct oral anticoagulants (OACs)., Materials and Methods: In the prospective multicenter CODE-AF registry, 10529 patients with AF were evaluated. Multivariate analyses were performed to identify variables associated with the use of anticoagulants., Results: The mean age of the patients was 66.9±14.4 years, and 64.9% were men. The mean CHA₂DS₂-VASc and HAS-BLED scores were 2.6±1.7 and 1.8±1.1, respectively. In patients with high stroke risk (CHA₂DS₂-VASc ≥2), OACs were used in 83.2%, including direct OAC in 68.8%. The most important factors for non-OAC treatment were end-stage renal disease [odds ratio (OR) 0.27; 95% confidence interval (CI): 0.19-0.40], myocardial infarct (OR 0.53; 95% CI: 0.40-0.72), and major bleeding (OR 0.57; 95% CI: 0.39-0.84). Female sex (OR 1.40; 95% CI: 1.21-1.61), cancer (OR 1.78; 95% CI: 1.38-2.29), and smoking (OR 1.60; 95% CI: 1.15-2.24) were factors favoring direct OAC use over warfarin. Among patients receiving OACs, the rate of combined antiplatelet agents was 7.8%. However, 73.6% of patients did not have any indication for a combination of antiplatelet agents., Conclusion: Renal disease and history of valvular heart disease were associated with warfarin use, while cancer and smoking status were associated with direct OAC use in high stroke risk patients. The combination of antiplatelet agents with OAC was prescribed in 73.6% of patients without definite indications recommended by guidelines., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2020.)

It is unknown whether heart failure (HF) with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) carry a similar risk of stroke or systemic embolism (SE) and other outcomes in patients with nonvalvular atrial fibrillation (AF). A prospective, multicenter outpatient registry with echocardiographic data which enrolled 10,589 patients from June 2016 to May 2019 was analyzed. In this registry, 935 (8.8%) patients had HF, and the proportions of patients with HFpEF and HFrEF were 43.2% and 56.8%, respectively. During follow-up over 1.33 years, 11 (2.07 per 100 person-years [PYR]) and 5 (0.76 per 100 PYR) patients had stroke/SE in the HFpEF and HFrEF groups, respectively, whereas 102 patients (0.84 per 100 PYR) had these sequelae in the no-HF group. The HFpEF group had a significantly higher cumulative incidence of stroke/SE (p = 0.004) and risk of stroke/SE (adjusted hazard ratio [HR] 2.23, 95% confidence interval [CI] 1.19 to 4.18) than the no-HF group. The risk of stroke/SE in the HFpEF group compared with that in the no-HF group was consistently increased even in patients on oral anticoagulation therapy (adjusted HR 2.55, 95% CI 1.31 to 4.96). There was a correlation between larger left atrial size and risk of stroke/SE (adjusted HR 1.53, 95% CI 1.03 to 2.29), but not between reduced left ventricular ejection fraction and this risk. In conclusion, these results suggest that strict oral anticoagulation therapy helps reduce the risk of stroke/SE in patients with nonvalvular AF and HFpEF, especially in those with a larger left atrial size., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/aims: Efforts to reduce stroke in patients with atrial fibrillation (AF) have focused on increasing physician adherence to oral anticoagulant (OAC) guidelines; however, the high early discontinuation rate of vitamin K antagonists (VKAs) is a limitation. Although non-VKA OACs (NOACs) are more convenient to administer than warfarin, their lack of monitoring may predispose patients to nonpersistence. We compared the persistence of NOAC and VKA treatment for AF in real-world practice., Methods: In a prospective observational registry (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation [CODE-AF] registry), 7,013 patients with nonvalvular AF (mean age 67.2 ± 10.9 years, women 36.4%) were consecutively enrolled between June 2016 and June 2017 from 10 tertiary hospitals in Korea. This study included 3,381 patients who started OAC 30 days before enrollment (maintenance group) and 572 patients who newly started OAC (new-starter group). The persistence rate of OAC was evaluated., Results: In the maintenance group, persistence to OAC declined during 6 months, to 88.3% for VKA and 95.5% for NOAC (p < 0.0001). However, the persistence rate was not different among NOACs. In the new-starter group, persistence to OAC declined during 6 months, to 78.9% for VKA and 92.1% for NOAC (p < 0.0001). The persistence rate was lower for rivaroxaban (83.7%) than apixaban (94.6%) and edoxaban (94.1%, p < 0.001). In the new-starter group, diabetes, valve disease, and cancer were related to nonpersistence of OAC., Conclusion: Nonpersistence was significantly lower with NOAC than VKA in both the maintenance and new-starter groups. In only the new-starter group, apixaban or edoxaban showed higher persistence rates than rivaroxaban.

Objectives: This study explored whether complete electrical isolation of the left atrial (LA) posterior wall improves the rhythm outcome of catheter ablation of persistent atrial fibrillation (AF)., Background: Although the STAR AF2 (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial Part II) proved no additional benefit of empirical extra-pulmonary vein (PV) LA ablation, the long-term recurrence rate after circumferential PV isolation (CPVI) alone remains high., Methods: We randomly assigned 217 patients with persistent AF (83.1% men, age 58.7 ± 10.8 years, 73.3% long-standing persistent AF) to ablation with CPVI alone (CPVI group) or CPVI with a POsterior wall Box Isolation (POBI group). The endpoint of the POBI group was the elimination of the posterior atrial potentials by roof and posterior inferior lines and touch-up focal ablation., Results: After a mean follow-up of 16.2 ± 8.8 months, the clinical recurrence rate did not significantly differ between the 2 groups (23.8% vs. 26.5%; p = 0.779) in the CPVI and POBI groups. The recurrence rate for atrial tachycardias (16.0% vs. 11.1%; p = 0.913) and cardioversion rates (6.7% vs. 13.7%; p = 0.093) to control clinical recurrences also did not significantly differ between the 2 groups. At the final follow-up, sinus rhythm was maintained without antiarrhythmic drug in 50.5% and 55.9% in the CPVI and POBI groups, respectively (p = 0.522). No significant difference was found in the major complication rates between the 2 groups, but the total ablation time was significantly longer in the POBI group (4,289 ± 1,837 s vs. 5,365 ± 2,358 s; p < 0.001)., Conclusions: In patients with persistent AF, an empirical complete POBI did not improve the rhythm outcome of catheter ablation or influence the type of recurrent atrial arrhythmia. (Comparison of Circumferential Pulmonary Vein Isolation Alone Versus Linear Ablation in Addition to Circumferential Pulmonary Vein Isolation for Catheter Ablation in Persistent Atrial Fibrillation: Prospective Randomized Controlled Trial; NCT02721121)., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: Label adherence for non-vitamin K antagonist oral anticoagulants (NOACs) has not been well evaluated in Asian patients with non-valvular atrial fibrillation (AF). The present study aimed to assess label adherence for NOACs in a Korean AF population and to determine risk factors of off-label prescriptions of NOACs., Materials and Methods: In this COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, patients with AF who were prescribed NOACs between June 2016 and May 2017 were included. Four NOAC doses were categorized as on- or off-label use according to Korea Food and Drug Regulations., Results: We evaluated 3080 AF patients treated with NOACs (dabigatran 27.2%, rivaroxaban 23.9%, apixaban 36.9%, and edoxaban 12.0%). The mean age was 70.5±9.2 years; 56.0% were men; and the mean CHA₂DS₂-VASc score was 3.3±1.4. Only one-third of the patients (32.7%) was prescribed a standard dose of NOAC. More than one-third of the study population (n=1122, 36.4%) was prescribed an off-label reduced dose of NOAC. Compared to those with an on-label standard dosing, patients with an off-label reduced dose of NOAC were older (≥75 years), women, and had a lower body weight (≤60 kg), renal dysfunction (creatinine clearance ≤50 mL/min), previous stroke, previous bleeding, hypertension, concomitant dronedarone use, and anti-platelet use., Conclusion: In real-world practice, more than one-third of patients with NOAC prescriptions received an off-label reduced dose, which could result in an increased risk of stroke. Considering the high risk of stroke in these patients, on-label use of NOAC is recommended., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2019.)

Exercise intolerance among the clinical symptoms in patients with atrial fibrillation (AF) has usually been masked by their adjusted life style. We sought to assess the role of CHA 2 DS 2 -VASc score to predict exercise intolerance in asymptomatic AF patients, and further examine whether the relationship differs by age and gender. Among the 6,275 participants of the prospective Korean registry of the Comparison study of Drugs for symptom control and complication prevention of Atrial Fibrillation (CODE-AF), 1,080 AF patients who underwent exercise treadmill testing were studied. Exercise intolerance was defined as a peak exercise capacity of 7 metabolic equivalents (METs) or less, and the patients were divided into two groups for the analysis: ≤7 METs (n = 131) and >7 METs (n = 949). Patients with exercise intolerance had a significantly higher CHA 2 DS 2 -VASc score than those without (3.1 ± 1.3 vs. 2.0 ± 1.5, p < 0.0001). In the multivariate analysis, a higher CHA 2 DS 2 -VASc score (OR 1.54, 95% CI 1.31-1.81, p < 0.0001), corrected QT interval (OR 1.01, 95% CI 1.00-1.02, p = 0.026), and increased left atrial volume index (OR 1.02, 95% CI 1.01-1.03, p = 0.001) were found to be independent predictors of exercise intolerance. The impact of the CHA 2 DS 2 -VASc score on exercise intolerance was significant only in male patients aged <65 years (OR 3.30, 95% CI 1.76-6.19, p < 0.0001). The CHA 2 DS 2 -VASc score may be a feasible risk assessment tool to predict exercise intolerance, especially in young and middle-aged male patients with asymptomatic AF.

Background: Vitamin K antagonist (VKA) to prevent thromboembolism in non-valvular atrial fibrillation (NVAF) patients has limitations such as drug interaction. This study investigated the clinical characteristics of Korean patients treated with VKA for stroke prevention and assessed quality of VKA therapy and treatment satisfaction., Methods: We conducted a multicenter, prospective, non-interventional study. Patients with CHADS 2 ≥ 1 and treated with VKA (started within the last 3 months) were enrolled from April 2013 to March 2014. Demographic and clinical features including risk factors of stroke and VKA treatment information was collected at baseline. Treatment patterns and international normalized ratio (INR) level were evaluated during follow-up. Time in therapeutic range (TTR) > 60% indicated well-controlled INR. Treatment satisfaction on the VKA use was measured by Treatment Satisfaction Questionnaire for Medication (TSQM) after 3 months of follow-up., Results: A total of 877 patients (age, 67; male, 60%) were enrolled and followed up for one year. More than half of patients (56%) had CHADS 2 ≥ 2 and 83.6% had CHA 2 DS 2 -VASc ≥ 2. A total of 852 patients had one or more INR measurement during their follow-up period. Among those patients, 25.5% discontinued VKA treatment during follow-up. Of all patients, 626 patients (73%) had poor-controlled INR (TTR < 60%) measure. Patients' treatment satisfaction measured with TSQM was 55.6 in global satisfaction domain., Conclusion: INR was poorly controlled in Korean NVAF patients treated with VKA. VKA users also showed low treatment satisfaction., Competing Interests: Disclosure: The authors have no potential conflicts of interest to disclose.

Purpose: Comparisons of rhythm and rate control strategies for stroke prevention in patients with atrial fibrillation (AF) are still inconclusive. We compared differences in clinical outcomes between the rhythm and rate control strategies., Materials and Methods: The COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry prospectively enrolled 6000 patients who were treated for AF using real-world guideline adherence at multiple referral centers. In total, 2508 (41.8%) patients were clinically followed up for over six months. Of these, 1134 (45.2 %) patients treated by rhythm control and 1374 (54.8 %) patients treated by rate control were analyzed for clinical outcomes, including stroke and cardiovascular outcomes., Results: Among all patients (age, 68±10 years; male, 62.4%), those treated with the rhythm control strategy were significantly younger, had more symptomatic paroxysmal AF, and a shorter AF duration, and were less likely to have diabetes, renal dysfunction, and heart failure, compared to those treated with the rate control strategy (CHA₂DS₂-VASc score 2.4±1.5 vs. 3.1±1.7, p<0.001). Even though oral anticoagulation was similarly prescribed in both groups, occurrence of stroke was less likely to occur in the rhythm control strategy group (0.0% vs. 0.7%, p=0.015). Multivariate Cox hazard regression showed that only age, especially more than 75 years old, were significantly correlated with the occurrence of stroke, regardless of the strategy used for treatment., Conclusion: In this prospective AF cohort, compared with the rate control strategy, the rhythm control strategy was associated with fewer cardiovascular events and strokes in a short-term period., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2018)

Background: Strokes occur in some patients with atrial fibrillation (AF), even when the CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age>65 years, female sex) score is low., Objective: We sought to determine the factors defining the residual stroke risk in patients with AF and low CHA 2 DS 2 -VASc scores, with a particular focus on the hemodynamics and geometry of the left atrial appendage (LAA)., Methods: From February 1, 2008 to December 31, 2012, 66 consecutive patients with nonvalvular AF and a CHA 2 DS 2 -VASc score of 0 or 1 (except a point for the female sex) were enrolled. All patients were admitted with a diagnosis of acute ischemic stroke. The control group consisted of patients with nonvalvular AF without a history of stroke., Results: The LAA orifice area was larger (4.35 ± 1.51 cm 2 vs 2.83 ± 0.9 cm 2 ; P < .001) and the LAA flow velocity was lower (41.9 ± 22.7 cm/s vs 54.4 ± 19.9 cm/s; P < .001) in the stroke group than in the control group. Low LAA flow velocity (<40 cm/s) and large LAA orifice area (>4 cm 2 ) were independent predictors of stroke. Patients with an LAA flow velocity of <40 cm/s and an LAA orifice of >4.0 cm 2 had a markedly higher odds ratio (odds ratio 10.9; 95% confidence interval 3.0-40.0; P < .001) of stroke than did those with preserved LAA flow velocity and smaller LAA orifice., Conclusion: Even in patients with low CHA 2 DS 2 -VASc scores, the presence of both decreased LAA flow velocity and increased LAA orifice size was associated with a high odds ratio of stroke. Future large prospective studies are needed to assess whether these patients should receive anticoagulants., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objective: To explore the experiences of patients with atrial fibrillation (AF) in the context of a prospective, two-parallel-armed, participant-blinded and assessor-blinded sham-controlled randomised trial., Design: A nested qualitative study within an ongoing randomised controlled trial to explore acupuncture's antiarrhythmic effects on drug refractory acupuncture in persistent atrial fibrillation (AF) (ACU-AF trial)., Participants: Participants were recruited using purposeful sampling and a maximum variation strategy with regard to treatment allocation (treatment or control) and protocol completion (completion or non-completion)., Setting: This was a single-centre in-depth interview qualitative study conducted at a tertiary-level university hospital in Seoul, Republic of Korea., Results: Data saturation was reached after 8 participants. Thematic analysis identified that most patients were not aware of their condition until medical check-up; physician referral was the main reason for trial participation, and patients had high expectations regardless of previous acupuncture experiences. Patients tended to depend on their physicians' opinions because they felt helpless of their condition. No one questioned their assigned treatment groups and generally believed acupuncture treatment was different for cardiovascular diseases. A few patients expressed disappointment in the strict and rigid protocols, in which most practitioners refrained from explaining their acupuncture procedures., Conclusions: For cardiovascular patients their physician's advice was one of the biggest reasons for enrolling in the acupuncture trial therefore relying on standard recruitment methods may not be effective. Fortunately both real and sham acupuncture groups in our sample were receiving treatment as intended, but in the future, designing a more pragmatic trial (better reflecting clinical settings, expanding the inclusion criteria and using more treatment points) will allow researchers to better explore the comprehensive effects of acupuncture. The findings of this study will allow researchers to improve the currently ongoing ACU-AF trial and to further help interpretation of main trial outcomes once the trial is completed., Trial Registration Number: NCT02110537., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Atrial fibrillation (AF) is known to be associated with several pathophysiological mechanisms including endothelial dysfunction of the heart and arterial vessels. Recent evidence suggests that new oral anticoagulant (NOAC) treatment may improve endothelial function and the inflammatory process involved in atherosclerosis in AF patients. This study is designed to determine the efficacy of NOAC therapy in the prevention of endothelial dysfunction and the progression of atherosclerosis of AF subjects., Method/design: AF patients with a CHA2DS2-VASc score >2 and no previous history of overt coronary disease, severe peripheral arterial disease (PAD) or major stroke will be registered and randomly assigned either to the NOAC group (dabigatran or rivaroxaban) or the warfarin group in this prospective, randomized, 2-year follow-up study. Reactive hyperemia peripheral arterial tonometry (RH-PAT) measurements reflecting endothelial function will be conducted using the Endo-PAT2000 device. Left and right carotid intima-media thickness (IMT) will be measured at baseline, 12 months, and 24 months. The primary endpoint is defined as change in Reactive Hyperemia Index (RHI) at 12 months. Secondary endpoints included changes in the right and left maximum IMT of the common carotid artery (CCA) and internal carotid artery (ICA), the mean IMT of the CCA and ICA at 24 months, and 24-month cardiovascular events including cardiac death, stroke, acute myocardial infarction (AMI), overall cause of death, withdrawal of drug, or bleeding events., Discussion: This is the first study to evaluate the efficacy of NOAC therapy for the prevention of endothelial dysfunction and progression of atherosclerosis in AF subjects. These findings are expected to expand the knowledge of NOAC pleotropic action in AF patients., Trial Registration: ClinicalTrials.gov: NCT02544932 , registered on 7 September 2015.

Background: Whether routine transesophageal echocardiography (TEE) in addition to multidetector computed tomography (MDCT) has incremental value in preventing periprocedural stroke before atrial fibrillation (AF) ablation is unclear., Objective: The purpose of this study was to evaluate whether screening with MDCT is sufficient for preventing periprocedural stroke., Methods: From 4 tertiary centers, we enrolled 1147 patients (902 males, age 57 ± 11 years) with optimal anticoagulation and preserved left ventricular ejection function who had undergone MDCT and routine TEE (group 1, n = 678) or selective TEE (group 2, n = 469) as screening tests before AF ablation. Based on a propensity score analysis, 2 groups with 412 matched pairs were created., Results: Patient baseline characteristics were comparable between the matched groups. In group 1 (n = 412), thrombi were detected in 4 patients (1.0%) on TEE, and ablation was not performed. These patients also showed thrombi (n = 3) or blood stasis (n = 1) on MDCT. For thrombi detection, MDCT had sensitivity and negative predictive value of 100%. In group 2 (n = 412), thrombi were detected in 7 patients (1.7%) on MDCT. Of these patients , 2 (0.5%) also showed thrombi on TEE. Periprocedural stroke incidence did not differ between the groups (0.2% each, P = 1.0)., Conclusion: The incidence of periprocedural stroke was low and did not differ significantly between the group assigned to routine TEE vs selective TEE screening in AF patients undergoing anticoagulation therapy if the patients had conditions associated with low thrombus risk. Thus, preprocedural TEE may not be necessary before AF ablation in patients who have undergone preprocedural cardiac MDCT that shows no evidence of left atrial appendage thrombus., (Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Hybrid therapy with catheter ablation of the cavo-tricuspid isthmus (CTI) and continuation of anti-arrhythmic drugs (AAD), or electrical cardioversion with AADs might be alternative treatments for patients with persistent atrial fibrillation (AF). The goal of study was to assess the long term success rate of hybrid therapy for persistent AF compared to antiarrhythmic medication therapy after electrical cardioversion and identify the independent risk factors associated with recurrence after hybrid therapy., Materials and Methods: A total of 32 patients with persistent AF who developed atrial flutter after the administration of a class Ic or III anti-arrhythmic drug were enrolled. This group was compared with a group (33 patients) who underwent cardioversion and received direct current cardioversion with AADs. Baseline data were collected, and electrocardiogram and symptom driven Holter monitoring were performed every 2-4 months., Results: There was no significant difference in the baseline characteristics between the groups. The 12 month atrial arrhythmia free survival was better in the hybrid group, 49.0% vs. 33.1%, p=0.048. However, during a mean 55.7+/- 43.0 months of follow up, the improved survival rate regressed (p=0.25). A larger left atrium size was an independent risk factor for the recurrence of AF after adjusting for confounding factors., Conclusion: Despite favorable outcome during 12 month, the CTI block with AADs showed outcomes similar to AAD therapy after electrical cardioversion over a 12 month follow up period. Minimal substrate modification with AADs might be an alternative treatment for persistent AF with minimal atrial remodeling.

Background: The purpose of this study was to investigate the relationship between the efficacy of the 2 different ablation techniques of atrial fibrillation (AF) and left atrial (LA) size., Methods and Results: A total of 81 patients with paroxysmal AF (n = 58) or persistent AF (n = 23) refractory to antiarrhythmic drugs underwent circumferential pulmonary vein isolation (PVI; n = 45) or PVI (n = 36) without respect to echocardiographic results for LA volume index (LAVI). Of the 81 patients, 41 had less dilated LA (group 1; LAVI < 27 cc/m(2)) and 40 had dilated LA (group 2; LAVI > or = 27 cc/m(2)). During the 9-month follow-up, 33 patients (73.3%) after circumferential PVI and 18 (50%) after PVI (P = .031) were free of arrhythmia. The risk of recurrence was associated with persistent AF, hypertension, LAVI > 27 ml/m(2), PVI, early recurrence of AF, and lower left ventricular (LV) ejection fraction (all P value <.05). In the univariate analysis of each group, PVI (hazard ratio [HR]: 2.92, 95% confidence interval [CI]: 0.12-7.08, P = .018) was associated with late recurrence only in group 2. Cox regression analysis also showed that PVI (HR: 5.6, 95% CI: 1.9-16.56, P = .002) was a significant independent predictor of recurrence only in group 2., Conclusions: Circumferential PVI is more effective than PVI only in patients with a structural change of the atria, that is, a dilated LA. Our study suggests that a successful outcome in dilated LA may depend on wide modification of LA electroanatomical substrates, but wide ablation in less dilated LA may be unnecessary. Different technical strategies according to LA size are required for more a effective outcome., (Copyright (c) 2009 Wiley Periodicals, Inc.)

The objective of this work was to assess the predictive value of pre-procedural N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients undergoing atrial fibrillation (AF) ablation. Seventy-three consecutive patients with AF (paroxysmal n = 49, persistent n = 24) and preserved left ventricular (LV) systolic function (LV ejection fraction > 45%) were prospectively enrolled in this study. All of the enrolled patients underwent catheter ablation after a measurement of their plasma NT-proBNP levels, and an echocardiographic examination with assessment of their LV diastolic function and left atrial(LA) volume. Patients with AF recurrence at 3 months had more persistent AF (P = 0.001), a higher LA volume index (P = 0.002), lesser decelerating times (DT) of mitral inflow (P = 0.014), and higher NT-proBNP levels (P < 0.001), when compared with patients with sinus rhythm restoration. The baseline log NT-proBNP correlated significantly with age (r = 0.26, P = 0.025), LA volume index (r = 0.41, P = 0.001), E/E' (r = 0.34, P = 0.007), DT (r = -0.34, P = 0.007), and E (r = 0.25, P = 0.04). The log NT-proBNP (HR 7.76, 95% CI 2.95-20.39, P < 0.001) was an independent predictor of AF recurrence. The measurement of NT-proBNP added incremental predictive value to standard indexes of LA size or diastolic function, including LA volume index and DT (P = 0.02). This study suggests the clinical utility of the level of NT-proBNP as an integrating marker of various risk factors, and as an incremental predictive marker for AF catheter ablation.

Background/Objectives: Relatively little has been established about the association of rapid ventricular response (RVR) with further recurrence of atrial fibrillation (AF). This study investigated the impact of RVR on the recurrence of AF. Methods: Data were obtained from a multicenter, prospective registry of non-valvular AF patients. RVR was defined as AF with a ventricular rate > 110 bpm. The primary endpoint was the recurrence of AF, defined as the first AF detected on 12-lead electrocardiography during follow-up. Secondary endpoints included manifestation of AF during follow-up and major adverse cardiovascular events (MACEs), a composite of thromboembolic events, major bleeding, myocardial infarction, and death. Results: Among 5533 patients, 493 (8.9%) presented RVR. Patients with RVR were younger, had smaller left atrial diameters, and more frequently had paroxysmal AF. During the mean follow-up duration of 28.6 months, the RVR group exhibited significantly lower recurrence of AF (hazard ratio: 0.58, 95% confidence interval: 0.53–0.65, p < 0.001). There was no significant difference in the occurrence of MACEs between patients with RVR and those without RVR (0.96, 0.70–1.31, p = 0.800). AF with RVR was identified as an independent negative predictor of AF recurrence (0.61, 0.53–0.71, p < 0.001). Conclusions: In patients with AF, those with RVR had a significantly lower recurrence of AF without an increase in MACEs. RVR is a favorable marker that may benefit from early rhythm control. [ABSTRACT FROM AUTHOR]

Background: It is not clear whether the data regarding rhythm control during atrial fibrillation (AF) contained in AF registries is prognostically significant. Thus, this study investigated the relationship between rhythm control and cardiovascular outcomes in patients in contemporary AF registries. Methods: This study was conducted using data from 6670 patients with AF receiving oral anticoagulation in the CODE-AF registry. We used propensity overlap weighting to account for differences in baseline characteristics between the rhythm control and rate control groups. The primary outcome was a composite of the rate of death due to cardiovascular causes, stroke, acute coronary syndrome, and heart failure. The secondary outcomes were individual components of the primary outcome. Results: In the CODE-AF registry, 5407 (81.1%) patients were enrolled three months after AF diagnosis. During a median follow-up period of 973 days (interquartile range: 755–1089 days), a primary outcome event occurred in 72 patients in the rhythm control group (1.4 events per 100 person-years) and in 211 patients in the rate control group (1.8 events per 100 person-years). However, after overlap weighting, the incidence rates were 1.4 and 1.5 events per 100 person-years, respectively. No significant difference was found in either the primary outcome (weighted HR: 0.87; 95% CI: 0.66–1.17; p = 0.363) or secondary outcomes between the rhythm control and rate control groups. Conclusion: In a prospective AF registry in which most of the population was enrolled at least three months after AF diagnosis, no difference in the risk of cardiovascular or cerebrovascular outcomes was found between the rhythm control and rate control groups, suggesting the early rhythm control should be considered to improve the outcome of patients. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study is to determine the relationship between alcohol consumption and atrial fibrillation (AF)-related adverse events in the AF population.Methods and Results: A total of 9411 patients with nonvalvular AF in a prospective observational registry were categorized into four groups according to the amount of alcohol consumption-abstainer-rare, light (<100 g/week), moderate (100-200 g/week), and heavy (≥200 g/week). Data on adverse events (ischaemic stroke, transient ischaemic attack, systemic embolic event, or AF hospitalization including for AF rate or rhythm control and heart failure management) were collected for 17.4 ± 7.3 months. A Cox proportional hazard models was performed to calculate hazard ratios (HRs), and propensity score matching was conducted to validate the results. The heavy alcohol consumption group showed an increased risk of composite adverse outcomes [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.06-1.66] compared with the reference group (abstainer-rare group). However, no significant increased risk for adverse outcomes was observed in the light (aHR 0.88, 95% CI 0.68-1.13) and moderate (aHR 0.91, 95% CI 0.63-1.33) groups. In subgroup analyses, adverse effect of heavy alcohol consumption was significant, especially among patients with low CHA2DS2-VASc score, without hypertension, and in whom β-blocker were not prescribed.Conclusion: Our findings suggest that heavy alcohol consumption increases the risk of adverse events in patients with AF, whereas light or moderate alcohol consumption does not. [ABSTRACT FROM AUTHOR]

Background: Studies have shown that the concomitant use of a vitamin K antagonist (VKA) and an antiplatelet (APL) drug increased the bleeding risk and was less effective at preventing ischemic events. This study aimed to investigate the control status of international normalized ratio (INR) and the discontinuation rate of a VKA in patients taking VKA plus an APL drug compared with those taking a VKA alone. Methods: Data were extracted from the KORean Atrial Fibrillation Investigation II registry, a multicenter noninterventional prospective observational study. Nonvalvular atrial fibrillation (NVAF) patients with CHADS2 scores ≥ 1 who newly started (within 3 months) a VKA were enrolled and followed up for 1 year. Results: A total of 866 NVAF patients (mean age, 67.7 years; 60.3% men) without a bleeding history were divided into the VKA+APL (n = 229) and VKA alone (n = 637) groups. During follow‐up, mean INR level was lower in the VKA+APL group than in the VKA alone group (1.7 ± 0.8 vs 1.9 ± 0.9, P = 0.0005). INR levels were poorly controlled in both groups (66.1% and 64.7%, respectively). Patients in the VKA+APL group more frequently discontinued VKA than patients in the VKA alone group (28.8% vs 24.2%, P = 0.045). Major causes of VKA discontinuation were uncontrolled INR level and patient dissatisfaction or concerns. Conclusions: The conditions of NVAF patients were inadequately controlled with VKA with or without an APL. These findings suggest that other antithrombotic treatment options are warranted in NVAF patients to achieve INR control. [ABSTRACT FROM AUTHOR]

Background: Strokes occur in some patients with atrial fibrillation (AF), even when the CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age>65 years, female sex) score is low.Objective: We sought to determine the factors defining the residual stroke risk in patients with AF and low CHA2DS2-VASc scores, with a particular focus on the hemodynamics and geometry of the left atrial appendage (LAA).Methods: From February 1, 2008 to December 31, 2012, 66 consecutive patients with nonvalvular AF and a CHA2DS2-VASc score of 0 or 1 (except a point for the female sex) were enrolled. All patients were admitted with a diagnosis of acute ischemic stroke. The control group consisted of patients with nonvalvular AF without a history of stroke.Results: The LAA orifice area was larger (4.35 ± 1.51 cm2 vs 2.83 ± 0.9 cm2; P < .001) and the LAA flow velocity was lower (41.9 ± 22.7 cm/s vs 54.4 ± 19.9 cm/s; P < .001) in the stroke group than in the control group. Low LAA flow velocity (<40 cm/s) and large LAA orifice area (>4 cm2) were independent predictors of stroke. Patients with an LAA flow velocity of <40 cm/s and an LAA orifice of >4.0 cm2 had a markedly higher odds ratio (odds ratio 10.9; 95% confidence interval 3.0-40.0; P < .001) of stroke than did those with preserved LAA flow velocity and smaller LAA orifice.Conclusion: Even in patients with low CHA2DS2-VASc scores, the presence of both decreased LAA flow velocity and increased LAA orifice size was associated with a high odds ratio of stroke. Future large prospective studies are needed to assess whether these patients should receive anticoagulants. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is known to be associated with several pathophysiological mechanisms including endothelial dysfunction of the heart and arterial vessels. Recent evidence suggests that new oral anticoagulant (NOAC) treatment may improve endothelial function and the inflammatory process involved in atherosclerosis in AF patients. This study is designed to determine the efficacy of NOAC therapy in the prevention of endothelial dysfunction and the progression of atherosclerosis of AF subjects.Method/design: AF patients with a CHA2DS2-VASc score >2 and no previous history of overt coronary disease, severe peripheral arterial disease (PAD) or major stroke will be registered and randomly assigned either to the NOAC group (dabigatran or rivaroxaban) or the warfarin group in this prospective, randomized, 2-year follow-up study. Reactive hyperemia peripheral arterial tonometry (RH-PAT) measurements reflecting endothelial function will be conducted using the Endo-PAT2000 device. Left and right carotid intima-media thickness (IMT) will be measured at baseline, 12 months, and 24 months. The primary endpoint is defined as change in Reactive Hyperemia Index (RHI) at 12 months. Secondary endpoints included changes in the right and left maximum IMT of the common carotid artery (CCA) and internal carotid artery (ICA), the mean IMT of the CCA and ICA at 24 months, and 24-month cardiovascular events including cardiac death, stroke, acute myocardial infarction (AMI), overall cause of death, withdrawal of drug, or bleeding events.Discussion: This is the first study to evaluate the efficacy of NOAC therapy for the prevention of endothelial dysfunction and progression of atherosclerosis in AF subjects. These findings are expected to expand the knowledge of NOAC pleotropic action in AF patients.Trial Registration: ClinicalTrials.gov: NCT02544932 , registered on 7 September 2015. [ABSTRACT FROM AUTHOR]

Symptomatic mitral stenosis (MS) develops in 7% to 21% of patients after percutaneous mitral balloon valvotomy (PMV). Treatment options for these patients are surgical mitral valve replacement (MVR) or repeated PMV. However, no comparisons were made between these 2 procedures regarding long-term outcome. This retrospective study compares the long-term outcome of 888 patients with symptomatic MS after MVR or repeated PMV who underwent PMV from April 1988 to December 2003. Thirty-two patients subsequently underwent repeated PMV, and 59 patients underwent MVR for symptomatic MS. Mean follow-up was 85 ± 43 months with a maximum follow-up of 15 years. Patients with MVR have more unfavorable clinical characteristics, including a higher incidence of atrial fibrillation and severe mitral regurgitation. Event-free survival was similar between the 2 groups up to 40 months after the procedure; 3-year event-free survival rates were 96.6% for MVR patients and 90.0% for repeated PMV patients (p = 0.215). However, after 40 months, the outcome was more favorable for MVR. Comparing MVR versus PMV, 6-year event-free survival rates were 93.0% versus 75.9% (p = 0.036), and 9-year event-free survival rates were 90.4% versus 36.0% (p <0.001). In conclusion, the long-term outcome of patients with symptomatic MS after previous PMV was more favorable after MVR than after repeated PMV. These data suggest that MVR may be the preferred mode of therapy in patients with unfavorable valve morphologic characteristics and no co-morbid disease. [Copyright &y& Elsevier]

Background and Objectives: In this study, we attempted to determine the effects of acupuncture on cardiac remodeling and atrial fibrillation (AF) recurrence rates in patients with AF after electrical cardioversion (EC). Materials and Methods: We randomly assigned 44 patients with persistent AF to an acupuncture group or a sham acupuncture group. An electroacupuncture treatment session was administered once weekly for 12 weeks at four acupuncture points (left PC5, PC6, ST36, and ST37). Results: Among the 44 recruited participants, 16 (treatment group) and 15 (control group) completed the trial. The three-month AF recurrence rate (primary outcome) was not significantly different between the two groups. Following the completion of treatment, patients who had been treated with acupuncture had a significant reduction in left atrial volume index (42.2 ± 13.9 to 36.1 ± 9.7 mL/m2; p = 0.028), whereas no change in atrial size was observed in the sham acupuncture group. No serious adverse events were observed. The AF recurrence rate and cardiac function did not differ significantly between the two groups. At three months, the acupuncture treatment group showed more favorable atrial structural remodeling compared to the sham acupuncture group. Conclusion: In future research on acupuncture in AF management, it is recommended that the inclusion criteria be amended to include only symptomatic AF, that an appropriate control group is designed, and that the acupuncture treatment frequency is increased to several times per week. [ABSTRACT FROM AUTHOR]

This study was designed to determine the efficacy of a new oral anticoagulant (NOAC) therapy for the prevention of endothelial dysfunction and atherosclerosis progression in patients with atrial fibrillation (AF). Sixty-five AF patients with a CHA2DS2-VASc score ≥2 without previous history of cardiovascular disease were registered and randomly assigned to either an NOAC group (dabigatran or rivaroxaban) or the warfarin group. Reactive hyperemia peripheral arterial tonometry (RH-PAT) measurements reflecting endothelial function were taken using Endo-PAT2000. Carotid intima–media thickness (IMT) was measured at baseline, 12 months, and 24 months, and several biomarkers were also analyzed. For the primary end point, the reactive hyperemia index (RHI) for the NOAC group was 1.5 ± 0.4 and that for the warfarin group was 1.6 ± 0.5. The left and right carotid IMT was 0.7 mm in the NOAC groups and 0.8 mm in the warfarin group. At 12 months, RHI was 1.6 ± 0.3 for the dabigatran group, 1.6 ± 0.5 for the rivaroxaban group, and 1.6 ± 0.3 for the warfarin group. The three groups did not differ statistically with respect to change in left and right carotid IMT at 12 and 24 months, respectively. The biomarkers for endothelial function and atherosclerosis were not significantly different. There was a trend of reduced P-selectin levels in the NOAC group compared to the warfarin group. In patients with AF, there were no significant differences in the prevention of endothelial dysfunction and atherosclerosis progression between the NOAC and warfarin groups. [ABSTRACT FROM AUTHOR]